Inspection number OSHI ID Optional report no. Minnesota Department of Labor and Industry Occupational Safety and Health Division Employer’s name and mailing address 443 Lafayette Road N.

St. Paul, MN 55155-4307

Phone: 1-800-DIAL-DLI (1-800-342-5354) (651) 284-5050 Fax: (651) 284-5741 E-mail: [email protected]

PETITION FOR MODIFICATION OF ABATEMENT DATE

PURPOSE OF THIS FORM

This Petition for Modification of Abatement Date form (PMA form) should ONLY be completed by an employer that has received a Citation and Notification of Penalty from the Minnesota Occupational Safety and Health Division (MNOSHA), that wishes to request an extension of time to abate one or several items.

If the employer wishes to obtain an extension of time to pay a penalty, or contests any portion of a citation, the employer may file a Notice of Contest form according to the instructions on the Citation and Notification of Penalty. A petition for modification of abatement date is not necessary if a Notice of Contest form has been timely filed AND the Citation or the Abatement Date has been contested for those item(s) the employer wishes to receive an extension.

By filing this PMA form, the employer is initiating a formal request for additional time to complete a planned abatement. This form must be filed in good faith and not solely for delay.

Upon receipt of a timely filed PMA form, MNOSHA will review the information submitted and allow affected employees up to 10 days to notify MNOSHA of any objections they may have.

FILING THIS FORM

This PMA form must be filed with the commissioner of the Department of Labor and Industry at the above address no later than the next working day following the date on which abatement was originally required (or modified). To be considered filed, all parts of the PMA form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the commissioner at the above address, within the next working day after the original date the item was to be abated. Facsimile (fax) transmittal of this form is acceptable if received no later than 4:30 p.m. on the following day. If the employer fails to file the PMA form on time, the abatement date on the Citation becomes a final order of the commissioner, which is not subject to review by any court or agency.

COMPLETING THIS FORM

1. HOW TO IDENTIFY THE INSPECTION

The employer must complete the box at the top of page 1 of this form using the inspection number, OSHI ID, optional report number and employer's mailing address from the Citation and Notification of Penalty.

2. HOW TO POST AND SERVE THIS FORM

The employer must post a fully completed copy of both pages of this form and any additional explanatory pages, documents or letters where the Citation and Notification of Penalty is posted no later than the last day this form may be filed. The form must remain posted for 10 days.

If there are any affected employees who are represented by an authorized employee representative, the employer shall, on or before the date this form is required to be filed with the commissioner, serve a fully completed copy of the form upon the representative. Service may be accomplished by either postage prepaid first class mail or personal delivery. 3. DATE OF POSTING

The employer must certify in Box A or B below, the dates on which it posted and served this form.

A. Union: Employers that have affected employees represented by authorized employee representatives I hereby certify that I posted fully completed copies of this form on (date) at the locations where the Citation and Notification of Penalty is posted and I served fully completed copies of this form on (date) upon the authorized employee representatives of affected employees.

B. Non-union: Employers that have affected employees not represented by authorized employee representatives I hereby certify that I posted fully completed copies of this form on (date) at the locations where the Citation and Notification of Penalty is posted and that I do not have any affected employees who are represented by authorized employee representatives.

4. HOW TO REQUEST A MODIFICATION OF ABATEMENT DATE(S)

The employer must indicate in the boxes below which item(s) of the Citation and Notification of Penalty it wishes to extend. First, the employer must identify the citation and item number(s). (For example, "Citation 1, Item 2" or “1-2.”) Then the employer must indicate all actions taken, their dates, to achieve compliance during the original abatement period. The employer must also include: the specific additional time necessary, the reasons for the additional time, all available interim steps being taken to safeguard employees, a certification that a copy of this PMA has been posted and served upon the authorized employee representative, and the date the posting and service was completed, see part 3 above.

Citation Abatement Anticipated Reason for additional Interim steps taken to safeguard and item date on completion abatement period employees, including dates no. citation cate

5. The employer completing this form must sign the form.

Name of employer representative, title Phone

Signature Date

Additional copies of this form are available online at www.dli.mn.gov/OSHA/FormsMnosha.asp.